New today is a ‘midline catheter’. I wonder why they don’t call it an MLC? Almost everything is known by acronym. It’s maddening. And I think it should be a mid-length catheter – but I didn’t get to name it.
Catheters are short or long tubes that can be inserted into the body, in this case Nancy’s, for the injection of fluids. Thus, she gets one poke that will do for many days rather than multiple pokes. The down side is that you have the end sticking out and taped to your skin – often in an awkward place.
The midline catheter usually goes in on the arm near the elbow joint and runs up into the area just short of the axilla or near where the arm connects to the shoulder. I’ll get a look tomorrow.
Nancy had a PICC line (peripherally inserted central catheter) inserted last summer. That story began in April and you can search for endocarditis to catch up. Nancy had four different bacteria in her blood and the protocol was for 28 days of injections of about 30 minutes. That line went from about the same location near the elbow into the artery near her heart and so the medicine was released close to where it was needed.
Today, I was there for lunch and visits by a nutritionist and a social services case manager. The case manager gave us a large 3-ring binder with reading material designed to guide us through the recovery period, especially that time after Nancy leaves the hospital. There is also a section on pre-operation instructions and one on how to quit smoking. I’m thinking of buying a parakeet so I’ll have something to do with those pages.
Open heart surgery was last Tuesday, so I appoint that as day “zero” and today is day 5. They say time rushes by when you are having fun.
Actually, about half-way through our visit today Nancy said what day is this. We knew it was the 3rd but not the day of the week. Then I remembered I had picked up the Sunday morning paper – from Yakima – that we just started (Sundays only) a few weeks before she went to the hospital.
When one is working or has another regular schedule the days are easily kept track of. Not now, with us. Nancy has a TV but isn’t interested – nothing new there. At home we have a TV set but no reception. Last summer I almost did something about that, namely run a line to an aerial in the middle of the pasture 300 feet out. We bought a converter box also, but it seems a lot of work for such little reward.
We talked with the nurse some today and she claims many people do not remember these days after open heart surgery. Nancy and I are having very normal conversations and the medical staff will converse with us about many different things. It will be interesting to see what Nancy remembers of all this. I do need to take a calendar to her – at least we would know what day it is.
They did bring Nancy a breakfast she would eat – an omelette of some sort. I should have thought of that. Yesterday I promised to bring a real ice cream chocolate shake. About a mile before the hospital I stopped and bought one, she ate it, and then they brought lunch. Bad timing. Well, the lunch was green beans, white rice, and meat balls. Good luck with those. On a really hungry day she might eat the meat, the green beans never, and the white rice – probably not, or not much.
But progress is progress. Day five becomes known as the day she ‘started’ eating real food. The doctor claims this is necessary for her to flush (my word) the edema from her body and recover the look of a healthy person.
Day 6 or day 7 may be the day she sheds the chest drain. We spoke with the surgeon about it today but he wouldn’t commit. It even seems reasonable now to think of her leaving the ICU and going back to the fourth floor Advanced Care Unit (ACU). Then what?
I arrived today to find Nancy in a chair. It is not an easy task just yet for that to happen. She is still connected to a couple of drip lines, an oxygen line, and the chest cavity drain. She also has a suction line such as the one dental assistants use to clear your mouth. This is a great advance over having to cough and spit into tissue.
Some body chemistry is still marginal. Fluids are an issue partly because she is drinking a lot and not eating much solid food. Getting rid of the fluids takes out some of the desirable chemicals, such as calcium. While these things are easily correctable they do require monitoring, injections, and pills. They are also (and have been for awhile) giving her low doses of insulin, as in being diabetic. We think this may just be because of all the things that have happened and that it will not remain a long term issue.
Nancy is right handed and moves the right arm and hand more than the left. This shows in the degree of puffy-versus-normal in the appearance of her left hand. [The puffy or swollen aspect is referred to medically as edema, caused when fluid is retained in the spaces between body cells.]
Her lower legs are likewise swollen. This is her 37th day of being in bed, many with almost no movement. With the open heart surgery behind her it is a sign of progress that edema is the concern of the day.
Today, there was also the issue of the bed. I guess she has used it so much it needed to be replaced. So, before moving her from the chair with the Robin’s egg-blue “float” (a canvas like sling), the broken bed was moved out and a new one in. These things may not roast the Christmas turkey or fly you to your Hawaiian vacation but they are marvels of engineering and construction. They also cost about 50 grand.
Nancy continues to do well. We’d like her to eat more real food but at the moment she is not much inclined to do that.
She got a big red heart-shaped pillow for her new year. I didn’t know about these things until last night. The gentleman homeowner who hosted the potluck last night asked if Nancy had gotten her pillow? He had multiple by-pass surgery in the same hospital a few years back. When I said I had no idea what he meant, his wife brought out a large red pillow in the shape of a heart. This had an image of a heart on it and over that someone had drawn each of the by-passes that had been done inside his chest. Also, about a dozen people had signed it – doctors, nurses, and family.
I got home to find an e-mail asking the same question? “Did Nancy get her special pillow?” I’m I the only one that didn’t know of these?
Well it seems that when your chest is split open and then closed again that in the weeks to follow you have an urge to cough frequently. So as to keep it from opening again when you cough, you are told to hold a pillow tightly against your chest. A stuffed teddy bear is sometimes given but any pillow would do. It seems the red heart-shaped ones are the “special” ones – it could be considered a badge of courage and a statement that one survived.
Much of the very high-tech equipment was gone from Nancy’s room today. There remained a gizmo on the floor at the foot of her bed making the sounds of a little stream tumbling over rocks. This is part of a ‘chest drain’ and its purpose is to allow any fluid, blood, or pus to exit the ‘pleural’ cavity by way of a long tube. Translated into English this means ‘from the hole in your body where they were working.’ Seems to me the original meaning (now said to be side or rib) has gotten lost somewhere along the path from Greek to Latin to Middle English to the World Wide Web. A wine maker would recognize this as a “water sealed fermentation lock” with a vacuum assist through the water causing the bubbling sound.
Each of the two doctors on the floor visited briefly today and listened to her heart and lungs and pronounced her in good shape – for the shape she is in. Many times a heart patient in the ICU will only encounter one or two doctors during a stay of a few days. Today was Nancy’s 36th day there and she is on their (the doctor’s) third or fourth rotation. Somewhat uncommon we were informed.
MORNING : I spoke with the night nurse at 10 min. to 6 this morning. Nancy had a good night. The ventilator was still providing a little oxygen but no mechanical assist for breathing. So, lungs and heart (now minus the balloon pump) are doing their things. Ventilator tube is still in because they want to wait until later when the ICU is full of doctors – just in case the thing has to be put back in. She still has to communicate via them asking Yes/No questions or pointing at letters and she still has post-operative pain and is getting lots of pain medication. I know she felt frustrated yesterday because she could not talk to us.
NOON : Our horses got their feet trimmed this morning – after several postponements this month. Snow was falling softly as we finished. Travel highway-cameras showed snow on Interstate 82 and National Weather Service folks have issued a winter storm warning. I called to check on Nancy. She was still doing fine.
5 P. M. : I spoke with Nancy’s nurse earlier than usual because they had taken the ventilator tube out this afternoon and then a procession of doctors visited. Her voice is very soft but she asked the nurse to call me. I was out moving that white fluffy ‘insert your favorite term here’ off of the driveway so called back. Everyone seems to be pleased about Nancy’s progress following the operation, including Nancy.
Some of you know Nancy plays fiddle in a group that visits retirement, nursing, and rehabilitation centers. They play old-time country music –think Appalachian Mountain Music. With continued progress she will soon be in one of those places to which they go. Players and spouses are meeting tonight for a pot luck dinner and maybe a little music. There is other music I’d rather listen to (except for a few tunes) but the food is always good. So, I’m off to a place just 5 miles away. If it snows too much while I’m there it is close enough that I can walk home.
~~~~~~~~~~~~ HAPPY NEW YEAR ! ~~~~~~~~~~~~
I’ve heard that the first day after heart surgery is the most painful for the patient. Although Nancy was awake today she was being given several drugs of one sort or another and still was experiencing pain. When I arrived she still had an intra-aorta balloon pump going and was still on the ventilator. She was frustrated that she could not yet speak and her nurse was not happy that my presence was causing that frustration.
The surgeon was there and showed to me 2×3 inch pictures of Nancy’s mitral valve – both old and new. Quite interesting but I would like to see them full screen on my monitor at home along with one from a healthy human. No such luck. As part of the operation he also did two by-passes but I didn’t learn anything about that.
There was too much going on in the ICU today –and not just with Nancy.
Based on the readings they were getting from her heart they felt it was time to take out the post-operative balloon pump, so shortly after 1 P.M. they chased me from the area while they did that. By the time they allowed me back in I felt compelled to leave for home because they were wanting to shut down the ventilator and remove that also and I didn’t have the inclination to set in the waiting room watching the Weather Channel for a second hour. I already know that the atmosphere over the Northern Pacific is about to clobber the west coast of North America. Washington State is in between the two major thrusts, one south and one north of us. We get a mash-up of snow, rain, and freezing rain beginning sometime tonight.
I told Nancy I would come back at 7 P.M. but the driving conditions are suggesting otherwise. Fog is really thick in the low places and the tops of the ridges are at or below freezing. I drove through patches of thick fog on the way back north and at home I can see only a short distance. At dusk, while I was feeding and running water for the horses, I noticed a ‘silver frost’ had formed, and was still forming, on the trees.
I have plenty of pictures of such trees. This is not my picture but it is a rather nice image: http://www.flickr.com/photos/joka2000/2258434451/
“Silver frost” seems to be a Pacific Northwest term for this ice. . .
I did not find it here: http://en.wikipedia.org/wiki/Frost
I apologize for all the weather stuff. I don’t have anything else.
————— One: waiting
Nancy is still in the operating room as of 2:15 P. M. Because of the allergy to heparin other anticoagulation chemicals are being used and these apparently prolong the time needed.
Yesterday I wrote that the operation was scheduled for 7 A. M. but that is the time they began preparations with her. They wheeled her out of the ICU at about 9 A. M. and at this point I do not know exactly when the doctors actually started.
————— Two: news
The news is good. An operating room nurse called about 3:30 to say the surgeons were in the process of finishing the ‘closing’ and Nancy would soon be back in the ICU. They do not expect to have her off the ventilator and awake until Wednesday morning.
The nurse has promised to write a short English-language version of the operation for me to adapt and post here. That may take a day or so. A general idea of such operations can be found on the Web, and so, in case you are curious — below are two of the many pages I have looked at.
The Texas Heart Institute has web pages that provide descriptions of heart surgery. This first is an overview:
About half way down in this long page you can find a link to “Valve Repair or Replacement Surgery” (just below where “stenosis” and “regurgitation” are explained. Nancy’s problem was regurgitation. It is easier to click on the link on the page, but below is the page you are going to:
Here’s to a good tomorrow.
Nancy was in a good mood today and ate some real food. Actually, I took the innards out of a ground chicken sandwich which she dunked in hot tomato soup. Yum. Mostly she stuck with the high nutrition drinks that seem to be marketed to diabetics. Each has 9.9 grams of protein which she needs and hasn’t been getting in regular food.
Latest from “The Team” is that the operation to replace the valve(s) will be on Tuesday and currently scheduled for 7 A.M.
I suppose it is possible, but highly unlikely, Nancy could get bumped if there is an emergency because she is stable and she could remain so for a few more hours or even a day or so.
She can’t improve much, however, and the decision is to operate tomorrow morning. We met the doctor that will be operating the heart-lung machine, he reviewed all the current readings, talked with the nurse of the day and visited with us – as did another (new) cardiologist on the floor for the day. The surgeon visited Nancy during the late afternoon but I was home by then taking care of the horses and dogs.
We have read about and talked about this operation during the last four months. Knowing it is dangerous for her we accepted this quite some time ago. Still we did not count on the difficulties of the past month.
Your concern, hope, and prayers are appreciated.
Well, not quite! I left shortly before they were going to remove a sample of bone marrow from her breast bone. Ouch! This might normally be taken from the pelvic bone but currently Nancy can’t be turned over. Anyway, when taking a sample with a needle (or syringe) it is called aspiration. I’ve confirmed that the sample was taken but results are not back in the ICU.
Apparently a rapidly inflating and deflating balloon in an artery can whack a few blood cells and over time decrease their number. This is just one of the reasons why the balloon pump is not a long term fix to the profusion issue. The examination today is meant to strengthen the view that the pause seen in the recent increase in Nancy’s platelet count is balloon-caused and not from any problem in blood production in the marrow.
Nancy and I visited with the doctor that had inserted the balloon pump and a team hematologist. The latter’s view is of interest because Nancy’s blood cells reacted so strongly to the heparin and in the coming operation it will be the skill of the hematologist that balances the competing ‘clotting / not-clotting’ characteristics of her blood.
They did numb the area and gave her a pain pill and as I write this at about 5:30 she is sleeping.
The last couple of postings indicated the remarkable change in Nancy with the insertion of the intra-aortic balloon pump. This was the hoped for result because it shows that improved heart function will likely bring adequate oxygenated blood flow to Nancy’s body.
The nature of this artificial assist is such that it cannot be continued indefinitely – although it can be in place for more than a few days. The issue is that while Nancy needs open heart surgery she is in poor health. A few days with the balloon pump assist and good nutrition makes sense but a prolonged delay provides additional time for more complications from the already compromised heart.
The surgeon who will perform Nancy’s operation had reviewed her case and visited her yesterday while she was sleeping. During my mid-day visit today, he met with the two of us. This was a general discussion about the issue of valve leakage and the effects on heart and body health. A few months ago we obtained a book on heart valve surgery and I’ve taken a lot of material off of the Web, and so we are not unaware of the material discussed today with the surgeon. For someone in Nancy’s state of health, open heart surgery is dangerous. There isn’t an alternative.
The team of doctors includes the surgeon, a cardiologist, hematologist, pulmonologist, and anesthesiologist – maybe more. These folks will meet early next week to consider the pending surgery. As of Noon today neither the meeting of “The Team” nor the surgery have been scheduled.
After our meeting with the surgeon Nancy had another ‘high nutrition’ drink and went to sleep.